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Management of End Hole in Placement of Port-Catheter System for Continuous Hepatic Arterial Infusion Chemotherapy Using the Fixed Catheter Tip Method

Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii, Kawaramachi-Hirokoji, Kamigyo, Kyoto 602-8566, Japan.

View larger version (18K): [in a new window]   Fig. 1A. —Schematic diagram of desired catheter position and occluded vessels for infusion using fixed catheter tip method and gastroduodenal artery. In original fixed catheter tip method, tip of catheter (thick arrow) is located in gastroduodenal artery, and side-hole (small arrowhead) through which anticancer drugs are infused via port and distributed to intrahepatic arterial branches is open toward common hepatic artery. Inside lumen of catheter tip is occluded with microcoil (long thin arrow). Catheter tip is tightly fixed in gastroduodenal artery with microcoils (short arrows) and mixture of n-butyl cyanoacrylate and Lipiodol (iodized oil, Guerbet) (large arrowhead) placed on outside of catheter. Right gastric artery and branches of pancreaticoduodenal arcade are embolized with microcoils. Note that side hole is created at region where diameter begins to taper (curved arrow) from 5 to 2.7 French. Diameter of implanted catheter positioned in common hepatic artery and celiac artery is 5 French. A = celiac artery, B = left gastric artery, C = splenic artery, D = common hepatic artery, E = gastroduodenal artery, F = proper hepatic artery, G = right gastric artery

View larger version (16K): [in a new window]   Fig. 1B. —Schematic diagram of desired catheter position and occluded vessels for infusion using fixed catheter tip method and gastroduodenal artery. In modified method, inside lumen of catheter tip is left open and gastroduodenal artery or right gastroepiploic artery beyond tip of indwelling catheter is embolized with one or two microcoils (long straight arrow). Note that point where narrowing of lumen begins is positioned in aorta (curved arrow). Side hole (arrowhead) is created in 2.7-French diameter, 20-cm-long distal shaft. Diameter of implanted catheter positioned in common hepatic artery and celiac artery is exclusively 2.7 French (short straight arrows).

View larger version (123K): [in a new window]   Fig. 2. —54-year-old woman with liver metastasis from breast cancer in whom port-catheter was placed with original fixed catheter tip technique. Arteriogram via port obtained just after implanting port-catheter system shows that indwelling port-catheter system is precisely implanted percutaneously. All hepatic arterial branches are shown. Distal tip of catheter is fixed to gastroduodenal artery with four microcoils and mixture of n-butyl cyanoacrylate and Lipiodol (iodized oil, Guerbet) (thick arrows). Distal lumen of indwelling catheter was occluded with microcoil (large arrowhead). Note that right gastric artery (short thin arrows), posterosuperior pancreaticoduodenal artery (long thin arrow), and aberrant left gastric artery (small arrowhead) are embolized with microcoils.

View larger version (161K): [in a new window]   Fig. 3A. —59-year-old woman with liver metastasis from colon in whom port-catheter was placed with modified fixed catheter tip technique Arteriogram obtained via 5-French catheter (small arrowhead) inserted from left subclavian artery shows good distribution into all intrahepatic arterial branches. In this patient, replaced right hepatic artery arising from superior mesenteric artery had been embolized with coils and n-butyl cyanoacrylate and Lipiodol (iodized oil, Guerbet) mixture (large arrowhead), and replaced left hepatic artery arising from left gastric artery had been embolized with coils (thick arrow) to redistribute hepatic arterial flow to allow complete hepatic coverage via a single infusion catheter before port-catheter placement. Note microcoils that were inserted into right gastric artery (thin arrow).

View larger version (126K): [in a new window]   Fig. 3B. —59-year-old woman with liver metastasis from colon in whom port-catheter was placed with modified fixed catheter tip technique Radiograph shows that microcatheter (arrowhead) is being advanced over microguidewire (arrow) already positioned with its tip in right gastroepiploic artery.

View larger version (162K): [in a new window]   Fig. 3C. —59-year-old woman with liver metastasis from colon in whom port-catheter was placed with modified fixed catheter tip technique Arteriogram obtained from indwelling catheter with side hole, which was advanced to planned position after exchanging previously inserted 5-French catheter and microcatheter with indwelling catheter, confirms that side hole (arrow) opens to common hepatic artery and all intrahepatic arterial branches are visualized.

View larger version (137K): [in a new window]   Fig. 3D. —59-year-old woman with liver metastasis from colon in whom port-catheter was placed with modified fixed catheter tip technique Radiograph shows tip of microcatheter (small arrow) advanced through 5-French catheter inserted from femoral artery with its tip in celiac axis (arrowhead). Note that microcoil inserted from this microcatheter is seen in right gastroepiploic artery beyond tip of indwelling catheter (large arrow).

View larger version (139K): [in a new window]   Fig. 3E. —59-year-old woman with liver metastasis from colon in whom port-catheter was placed with modified fixed catheter tip technique Arteriography via port obtained just after implanting port-catheter system shows that indwelling port-catheter system is precisely implanted percutaneously. Note that four microcoils (thick arrows), including microcoil positioned in right gastroepiploic artery, were put in gastroduodenal artery. Also note 2.7-French shaft part positioned in entire segment from celiac to common hepatic artery (thin arrows).

View larger version (131K): [in a new window]   Fig. 4A. —56-year-old man with hepatocellular carcinoma in whom port-catheter was placed with modified fixed catheter tip technique. Arteriogram via port obtained just after implanting port-catheter system shows that indwelling port-catheter system is precisely implanted percutaneously. However, although blood flow is not seen in segment of gastroduodenal artery in which embolic agents (thin arrows) were inserted, hepatofugal blood flow beyond indwelling catheter tip is seen (thick arrows), which suggests that inside lumen of catheter between side hole and end hole is not sufficiently closed. Note that five microcoils and mixture of n-butyl cyanoacrylate and Lipiodol (iodized oil, Guerbet) (thin arrows) were put into gastroduodenal artery. These five microcoils include microcoil positioned (arrowhead) in right gastroepiploic artery beyond tip of indwelling catheter.

View larger version (141K): [in a new window]   Fig. 4B. —56-year-old man with hepatocellular carcinoma in whom port-catheter was placed with modified fixed catheter tip technique. Arteriogram via port obtained 6 days after implanting port-catheter system shows no hepatofugal blood beyond indwelling catheter tip, which suggests that lumen of catheter between side hole and end hole has spontaneously closed.

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